DOI 10.1515/ijamh-2013-0318      Int J Adolesc Med Health 2014; 26(3): 411–416

Sebastian G. Kaplan*, Shahzad K. Ali, Brittany Simpson, Victoria Britt and W. Vaughn McCall

Associations between sleep disturbance and suicidal ideation in adolescents admitted to an inpatient psychiatric unit Abstract: The goals of our study were to: 1) describe the incidence of disturbances in sleep quality, sleep hygiene, sleep-related cognitions and nightmares; and 2) investigate the association between these sleep-related disturbances and suicidal ideation (SI), in adolescents admitted to a psychiatric inpatient unit. Our sample consisted of 50 adolescents between the ages of 12 and 17 years (32 females and 18 males; 41 Caucasian and nine African American). Our cross-sectional design involved the administration of the Adolescent Sleep Wake Scale (ASWS), the Adolescent Sleep Hygiene Scale (ASHS), the Dysfunctional Beliefs and Attitudes about Sleep-Short version for use with children (DBAS-C10), the Disturbing Dreams and Nightmare Scale (DDNSI), and the Suicidal Ideation Questionnaire Jr (SIQ-JR). Analyses were conducted using Pearson correlations, as well as univariate and multivariate regression. Results indicated that our sample experienced sleep disturbances and SI to a greater degree than non-clinical samples. Sleep quality was correlated with nightmares, while sleep quality and nightmares were each correlated with SI. Sleep quality, dysfunctional beliefs, and nightmares each independently predicted SI. Our study was the first to use the four sleep measures with an adolescent psychiatric inpatient sample. It is important to develop sleep-related assessment tools in high-risk populations given the link between sleep disturbances and suicidality. Furthermore, a better understanding of the relationships between SI and sleep quality, sleep-related cognitions, and nightmares is needed to develop potential prevention and treatment options for suicidality in adolescents. Keywords: assessment; sleep; suicidal ideation. *Corresponding author: Sebastian G. Kaplan, PhD, Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, 791 Jonestown Rd., Winston-Salem, NC 27103, USA, Phone: +336 716-3381, Fax: +336 716-9642, E-mail: [email protected] Shahzad K. Ali and Brittany Simpson: Department of Psychiatry and Behavioral Medicine, Child and Adolescent Psychiatry Section, Wake Forest University School of Medicine, Winston-Salem, NC, USA

Victoria Britt: Wake Forest University, Winston-Salem, NC, USA W. Vaughn McCall: Department of Psychiatry and Health Behavior, The Medical College of Georgia, Georgia Regents University, Augusta, GA, USA

Introduction Sleep plays a vital role in human growth and development and in the maintenance of mental health. Adolescence is a particularly important period of life as the individual undergoes a host of neurological, physiological, emotional, and interpersonal changes throughout this dynamic period. As a result, sleep in adolescence is an especially important area of clinical focus. Sleep problems are very prevalent in adolescence, with estimates of up to 60% of adolescents experiencing early onset insomnia and 46% having excessive daytime sleepiness at least once per week (1). One study reported an estimate of lifetime prevalence of insomnia during adolescence to be approximately 11% (2). A particularly serious problem for adolescents is suicide. The Centers for Disease Control and Prevention (CDC) reported that from the 2012 Youth Risk Behavior Survey, 7.8% of high school students attempted suicide in the preceding year (3). Nock et  al. (4) found that the lifetime prevalence of adolescent suicidal ideation (SI) was 12.1%, with 33.4% of “ideators” developing a plan and 33.9% making an attempt. Although a complex array of predictors of adolescent suicide exist (5), research has shown that sleep disturbances are associated with increased risk of suicidal thoughts and behavior. Wong and Brower (6) found that self-reported sleep difficulty increased the risk of suicidal thoughts and attempts, both concurrently and longitudinally, based on results from the National Longitudinal Study of Adolescent Health. Liu (7) showed that adolescents who reported sleeping   30 indicates a higher risk for suicide. Internal consistency was high in a standardization sample of 7th, 8th, and 9th graders (18)

Results Statistical analysis Data was analyzed using JMP version 10 (SAS Institute Inc., Cary, NC, USA, 1989–2012) statistical software. The distribution of each continuous variable was inspected to ensure that the assumptions of normality were met. A normal distribution was confirmed for age, SIQ-JR, DBAS, ASHS and ASWS, but DDNSI was slightly skewed to the right. Central tendencies were reported with means and standard deviations. Simple correlations were calculated with Pearson’s r. Multivariate linear regression was used to model SIQ-JR scores, using age, gender, ASWS, ASHS, DBAS, and DDNSI as independent variables. The model was refined by removing non-significant terms, except age and gender, which were consistently retained. Statistical significance was accepted at p  10. We did not find studies involving previous administrations of this measure with adolescents. The mean SIQ-Jr total score was 43.2, which exceeded the cut-off of 30 for a higher risk for suicide and should be expected for a sample drawn from a psychiatric inpatient population. Furthermore, 96% of adolescents endorsed at least some thoughts of death.

Correlations Table 2 shows Pearson correlations among the five measures. Between the four sleep measures, the only significant

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414      Kaplan et al.: Sleep and suicidal ideation Table 2 Summary of intercorrelations, means, and standard deviations for the SIQ-JR, DBAS-C10, DDNSI, ASWS, and ASHS total scores. Measure



1 

2 

3 

4 

5 

M 

SD

1. SIQ-Jr   2. DBAS-C10  3. DDNSI   4. ASWS   5. ASHS   M   SD  

–  –0.00  0.62c  –0.49b  0.08  43.20  26.30 

–0.00  –  0.21  –0.27  0.039  31.30  7.40 

0.62 c  0.21  –  –0.30a  0.04  11.30  10.00 

–0.49b  –0.27  –0.30 a  –  –0.03  3.40  0.90 

0.08  0.04  0.04  –0.03  –  3.30  0.70 

43.20  31.30  11.30  3.40  3.30     

26.30 7.40 10.00 0.90 0.70

SIQ-JR: Suicidal Ideation Questionnaire Jr., DBAS-C10: Dysfunctional Beliefs and Attitudes about Sleep-Short version for use with children, DDNSI: Disturbing Dream and Nightmare Severity Index, ASWS: Adolescent Sleep Wake Scale, ASHS: Adolescent Sleep Hygiene Scale, a p 

Associations between sleep disturbance and suicidal ideation in adolescents admitted to an inpatient psychiatric unit.

The goals of our study were to: 1) describe the incidence of disturbances in sleep quality, sleep hygiene, sleep-related cognitions and nightmares; an...
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